How i treat patients with barrett esophagus when endoscopic ablation fails

If initial ablation fails, it is usually beneficial to switch to a different mode of therapy. The Table shows the relative advantages and disadvantages of the alternatives to thermal ablation. Usually, thermal therapy with radiofrequency ablation is the first treatment modality. If the treatment fails to show demonstrable results after 3 applications in terms of decreasing both the Barrett mucosa and the degree of dysplasia, my preference is to use cryotherapy if there is persisting intestinal metaplasia. If there is persisting high-grade dysplasia or cancer or if nodules have arisen, then endoscopic resection is ideal, with endoscopic submucosal dissection being my first choice for complete removal. With recurrent disease, focal thermal therapy seems most cost-effective for small amounts of nondysplastic or low-grade dysplasia, whereas high-grade dysplasia or cancer usually is resected to ensure histologic confirmation of the adequacy of treatment. Submucosal recurrences and those of larger size generally require endoscopic submucosal dissection. All of these treatments should only be considered when the patient is expected to have sufficient longevity and health to be able to benefit. Otherwise, a strategy of surveillance or watchful waiting can be considered in patients with extensive serious comorbidities.